OBJECTIVE To assess the effect of intravenous versus topical tranexamic acid in reducing intraoperative and postoperative blood loss in women with abdominal hysterectomy. METHODS The study was a randomized double-blind placebo-controlled trial, carried out in a tertiary university hospital in Egypt, from November 2015 to October 2017. A total of 129 women undergoing abdominal hysterectomy for benign etiology were randomly assigned to three groups: Group I [43 patients received 110 ml normal saline IV just before skin in scion], Group II [43 patients received 1 g tranexamic acid in 100 ml saline IV just before skin in scion], and Group III [43 patients received 2 g topical tranexamic acid applied intra-abdominal after hysterectomy]. The primary outcome was intraoperative, postoperative, and all blood loss estimation. RESULTS Both Group II (IV tranexamic acid) and Group III (topical tranexamic acid application) showed great reduction in intraoperative and postoperative blood loss (blood in the intra-abdominal drain) compared with Group I (placebo group), (P = 0.0001, 0.0001, 0.0001, 0.0001), so the overall estimated blood loss in groups II and III showed highly reduction compared with Group I (P = 0.0001, 0.0001). CONCLUSIONS Intravenous and topical tranexamic acid application is a safe and reliable method to help decrease blood loss during and after abdominal hysterectomy.